A Conversation That’s Hard to Have, but Worth It

By: Chris Vogel​​​​​If you were in no condition to tell medical personnel how much treatment you’d want in the final stages of a chronic illness, would your loved ones have to guess? Or have you had conversations about end-of-life wishes? Are those wishes in writing in an advance medical directive?

​ A group of medical professionals in LaCrosse, Wisconsin decided to take a proactive approach to advance directives. Now more patients are having the conversation when they are able. Removing the burden of making difficult end-of-life decisions is enough reason to promote advanced directives, but this population also is experiencing another benefit–lower health care costs.

Cutting health care costs likely is the furthest thing from people’s minds as they weigh issues like quality of life and how they’d like to spend what might be their final weeks or months with family and friends. But it may have a place in the discussion.

In “High-Quality Communication Critical for Advanced Illness Patients,” the cover article in the June Benefits Magazine, Vital Decisions executive Matt Patella writes about the importance of effective discussions about what a chronically ill patient wants. He mentions the barriers—cultural, religious and behavioral—that make it so hard for people to talk about how aggressively a loved one should be treated with medicines and procedures. If nobody knows a patient’s wishes, he or she might be kept alive while incapable of enjoying life.

While the cost of health care is not a focus of his article, Patella mentions that the average cost of health care in a person’s last six months of life is a little more than $36,000, depending on the state. It’s a lot higher in some places, including in some parts of Wisconsin.

But according to a report I heard in March on NPR’s Market Place Money, La Crosse, Wisconsin spends less on health care than any other place in the country. Out of 306 regional markets, it’s at the very bottom in health care costs.

Chana Joffe-Walt’s report, The Town Where Everyone Talks About Death, makes a connection between La Crosse’s health care costs and the fact that in this city of a little over 50,000, it’s very unusual to find anyone who doesn’t have an advance directive about medical care. It turns out that if patients are allowed to choose and direct their care, they often choose a course that’s less expensive than would have been provided had their families had to guess patients’ wishes.

The NPR story of how people in La Crosse came to have so many conversations about death was interesting. A medical ethicist at Gundersen Health Systems in La Crosse said that for years he sat through excruciating discussions with families in the hospital and came to wonder why people didn’t have these conversations earlier, before a crisis point. So Bernard (Bud) Hammes, Ph.D., the health system’s director of medical humanities and Respecting Choices®, trained nurses to suggest that people fill out an advance directive.

“It took a while, but now those conversations happen all the time in La Crosse,” Joffe-Walt reported.

Patella wrote that advance directives may not be sufficient to make sure a patient’s wishes are taken into account. But they’re a start. Each state’s advance directive form is easily found by Googling.